Provider Demographics
NPI:1568471001
Name:DR. SUSAN P. WYNNE PLLC
Entity type:Organization
Organization Name:DR. SUSAN P. WYNNE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WYNNE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:425-882-2923
Mailing Address - Street 1:15600 REDMOND WAY
Mailing Address - Street 2:#300
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052
Mailing Address - Country:US
Mailing Address - Phone:425-882-2923
Mailing Address - Fax:425-968-8930
Practice Address - Street 1:15600 REDMOND WAY
Practice Address - Street 2:#300
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052
Practice Address - Country:US
Practice Address - Phone:425-882-2923
Practice Address - Fax:425-968-8930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2024-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty